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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 019200682
Report Date: 07/20/2023
Date Signed: 07/20/2023 06:13:51 PM

Document Has Been Signed on 07/20/2023 06:13 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
CCLD Regional Office, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612
FACILITY NAME:ELDRIDGE CARE HOMEFACILITY NUMBER:
019200682
ADMINISTRATOR:DIZON, MILLICENT RFACILITY TYPE:
735
ADDRESS:26601 ELDRIDGE AVENUETELEPHONE:
(510) 397-2056
CITY:HAYWARDSTATE: CAZIP CODE:
94544
CAPACITY: 6CENSUS: 6DATE:
07/20/2023
TYPE OF VISIT:Case Management - DeficienciesUNANNOUNCEDTIME BEGAN:
04:15 PM
MET WITH:Melinda Balingit/StaffTIME COMPLETED:
05:15 PM
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During the course of investigation of a complaint (Complaint Control # 15-AS-20220301161043), and upon review of resident's (R1) LIC621 Client/Resident Personal Property And Valuables, Licensing Program Analyst (LPA) Delmundo observed this document does not have the cell phone, iPad and other electronic items that were purchased for R1 listed. LPA had a discussion with Millicent Dizon, administrator, who stated that as administrator she should have the items listed.

Deficiency is cited from Title 22 California Code of Regulations, and listed on 809D Failure to submit proof of correction by plan of correction due date, and any repeat violation within 12 month period may result in civil penalty

Deficiency and plan and proof of correction were discussed with the administrator over the phone. Administrator authorized Melinda Balingit to sign and receive this report.

Exit interview conducted. Appeal Rights, LIC9098 Proof of Correction form and copy of this report provided.
SUPERVISORS NAME: Bennett Fong
LICENSING EVALUATOR NAME: Alicia Delmundo
LICENSING EVALUATOR SIGNATURE: DATE: 07/20/2023
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 07/20/2023
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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Document Has Been Signed on 07/20/2023 06:13 PM - It Cannot Be Edited


Created By: Alicia Delmundo On 07/20/2023 at 05:52 PM
Link to Parent Document Below:
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT (Cont)		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
, 1515 CLAY STREET, STE. 310
OAKLAND, CA 94612

FACILITY NAME: ELDRIDGE CARE HOME
FACILITY NUMBER: 019200682

DEFICIENCY INFORMATION FOR THIS PAGE:
VISIT DATE: 07/20/2023
Deficiency Type
POC Due Date /
Section Number
DEFICIENCIES
PLAN OF CORRECTIONS(POCs)
Type B
08/03/2023
Section Cited
CCR
80026(h)

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80026 Safeguards for Cash Resources, Personal Property, and Valuables of Residents (h) Each licensee shall maintain accurate records of accounts of cash resources, personal property, and valuables entrusted to his/her care......
-This requirement is not met as evidenced by:
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R1 is no longer at the facility.

Administrator to read the Regulations, and ensure that residents' records are complete. Self-certification to be submitted by 8/03/23.
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-Based on records review, the licensee did not comply with the section above for not keeping a complete record of R1's valuables and personal property which posed potential personal rights risk to person in care.
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Failure to correct the cited deficiency(ies), on or before the Plan of Correction (POC) due date, may result in a civil penalty assessment.
SUPERVISOR'S NAME:Bennett Fong
LICENSING EVALUATOR NAME:Alicia Delmundo
LICENSING EVALUATOR SIGNATURE:
DATE: 07/20/2023
I acknowledge receipt of this form and understand my appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 07/20/2023


LIC809 (FAS) - (06/04)
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